Patients left in the lurch as big health system and insurer duke it out in Pennsylvania

Published on
June 10, 2019

When you’re battling cancer, you can barely muster the energy to walk up a flight of stairs, let alone embark on a search for a whole new medical team. And yet that’s what people like me have been forced to do in western Pennsylvania, where thousands of cancer patients have been told they’d lose their access to the area’s premiere treatment facility, the Hillman Cancer Center in Pittsburgh, at the end of June.

A long-simmering dispute between two major health care companies is coming to a head here, and its outcome could pave the way for future hospital-versus-insurer showdowns across the country. 

The University of Pittsburgh Medical Center (UPMC), western Pennsylvania's largest health care system, and Highmark Blue Cross Blue Shield, one of its largest insurers, have been in conflict since 2011. That was the year Highmark bought a regional health system that put it in direct competition with UPMC's hospital network, which includes Hillman.

Since then, UPMC has sought to create its own health insurance plan and end its relationship with Highmark, leading up to a June 30 deadline imposed by UPMC that would end the rights of certain groups of Highmark insurees — seniors and cancer patients among them — to access care at UPMC. Highmark has sought to extend the agreement between the two; UPMC has repeatedly refused.

For me, this means I could be unceremoniously booted from Hillman, where a top-rated oncologist and his team got me through a year of treatment and recovery from stage 3 colorectal cancer. As anyone with a cancer diagnosis knows, one year is far from the end of monitoring, testing, and gradual recovery from the effects of surgery and chemotherapy (and for some, radiation as well).

On its face, this is a regional conflict, but the split should be on the radar of anyone who cares about health care, as it portends similar battles to come as more hospitals seek to consolidate their market power by branching out into insurance, and vice versa. It’s a trend that has been gaining steam, fueled by a broader shift away from fee-for-service payments for care.

UPMC has already closed its services to most patients covered by Highmark, encouraging them to drop their insurance and sign up for UPMC's own plan instead, despite the fact that many are insured through their work — including state employees — and do not have that option. “People who work for companies that only offer Highmark need to work with their employers to offer the insurance they want,” said UPMC’s chief communications officer, Paul Wood. “Come October, when most companies do open enrollment, I think you’re going to see a whole lot more of them offering plans other than Highmark.” 

"If no action is taken, some 200,000 people in Pennsylvania are going to lose access to the doctors and hospitals they've had longstanding relationships with," said Erin Ninehouser, director of campaigns at the consumer organization Pennsylvania Health Access Network. "There's a sense of betrayal a lot of people feel that (UPMC) should be working in the public interest, not seeking to excise half the community."

The state's attorney general, Josh Shapiro, filed a lawsuit against UPMC, alleging that it is acting in the interest of profit instead of patient wellbeing, as required by its legal standing as a charitable organization. UPMC’s Wood pushed back against this: “There is nothing in charitable laws or nonprofit hospital laws that compels a hospital to take all insurers at in-network rates,” Wood said. Highmark members are welcome to come to UPMC if they pay out of pocket, he added: “We are open to all.”

On its face, this is a regional conflict, but the split should be on the radar of anyone who cares about health care, as it portends similar battles to come as more hospitals seek to consolidate their market power by branching out into insurance, and vice versa. 

Patients in the region have been voicing alarm about the split for years. In mid-May, the consumer group Pennsylvania Health Access Network sponsored a trip to Harrisburg, the state capitol, so patients could share their stories with legislators and encourage them to support two legislative bills, one in the state House and one in the Senate, that would keep Highmark and UPMC together.

Among the attendees was 52-year-old Richard Callender, mayor of the Pittsburgh-adjacent city of Lower Burrell. He has been battling pulmonary fibrosis and its complications since he was 37, and had a lung transplant at UPMC, where he was initially sent by outside doctors. 

"I asked my pulmonologists, off the record, if you had my condition, where would you go? They said, we'd go to UPMC,” Callender recalled. “They have the expertise."

Now Callender, who is on a host of transplant support medications and has been seeing his doctors at UPMC for more than a decade, is being told by the company's billing department that he won't be allowed to see them after June 30. For a man who was initially given three to five years to live at his first diagnosis, this is infuriating. "My doctor to this day tells me I can still go there. The billing department says no. Who am I supposed to believe? And even if they're making a special exception for me, what about the other people?"

Ironically, UPMC has even featured Callender's lung transplant story on its website. "I've done public speaking for them," Callender says. "I speak to other patients who need transplants. And this is my thanks. It's crazy. It's all greed."

Another Highmark enrollee, 67-year-old Nancy Spohn, is angry as well. Too sick to accompany the PHAN group to Harrisburg, she filed a formal complaint over the impending split. She has been treated at UPMC Magee-Womens Hospital since her ovarian cancer diagnosis in 2015. "I've been very happy with them," she says. "I love my doctor. She's saved my life several times. They know things that affect me that nobody can get off a paper."

But she was encouraged to start seeing an oncologist outside the UPMC network due to the upcoming deadline, and so far it has not been a good match. "'I just can't tell you the stress this puts on me and everybody else [like me], to have to be dealing with this stuff when you're fighting for your life everyday," she says. "The greed, I just don't understand it. We get Highmark insurance through my husband's employer. We couldn't change if we had to." Regardless of which way the court rules on the AG's request to extend the deadline, the office's lawsuit will continue, though prospects may be dimmed if the entities are separated.

The legal battle took a new turn last Friday, when UPMC issued a press release saying it will relent and allow Highmark subscribers to continue to access Hillman Cancer Center at in-network rates. AG Shapiro called the announcement a “PR stunt,” saying, “None of this would have happened without our lawsuit. And I think it is also clear that if UPMC is serious they would stop firing off press releases to garner attention and instead actually commit this to writing and try to do this in a formal legal way and, to date, they have not done that.” 

The outcome of the case, which heads to court this week, has broader implications for the future of the health care system, none of which bode well for consumers. “When (hospitals) gain market power they have the ability to raise prices. They have the ability to gain more favorable contractual terms, which allows them to raise prices and resist the new, more sensible payment reforms,” Zack Cooper, associate professor of health policy at Yale University, told Modern Healthcare in February.

It doesn’t help that consumers generally have little idea about how prices are set or how or why they vary from one hospital to the next. “Hospitals continue to have the most leverage when it comes to setting and raising prices for all kinds of care,” columnist Jake Novak wrote at CNBC  in 2017. “But the insurance industry helps mitigate the potentially disastrous response to hospital price increases because people who have insurance don't pay full price … Imagine running an industry that has the power to raise prices without having to deal with public outrage when those prices are raised because its prices aren't published.”

Those of us at risk of becoming collateral damage in the current conflict are looking at hard choices due to UPMC’s unwillingness to negotiate until, it seems, the eleventh hour. 

Vikas Saini, president of the health care research nonprofit the Lown Institute, has also pointed to the growing market clout of hospitals as a growing problem. “Hospital consolidation is underway all over the US,” he told Jacobin. “This has been increasing the pricing power of the hospital sector in their bargaining with insurers, who have also been consolidating … Without a clear articulation of a path for the hospital sector, political conflict will rise, the affordability of hospital care will be strained, and the political credibility of solutions like Medicare for All will be under threat.”

Those of us at risk of becoming collateral damage in the current conflict are looking at hard choices due to UPMC’s unwillingness to negotiate until, it seems, the eleventh hour. By the time they announced the latest change in policy, this reporter had already switched to a new, out of state oncologist at Johns Hopkins in Baltimore. For many cancer patients, this won’t be an option, so their hopes rest on UPMC keeping its word. And for regular Highmark subscribers, the hospital network remains entirely off-limits. 

“The bottom line,” says consumer advocate Ninehouser, “is that these are charitable organizations. They shouldn't be forcing people into situations where they're going to either pay much more money or have to give up their doctors.”